The issue: Remedying a shortage of physician assistants (PAs) who have the appropriate knowledge
and training to work in a hospital medicine program.

Background

The Mayo hospitalist program hired its first physician assistant eight years ago.
As the program expanded, more PAs were brought on board, but finding applicants with
relevant experience had become more difficult in recent years. “The PAs we
had were spectacular, but as we were looking to expand, we found the job pool somewhat
lacking,” said Mayo hospitalist Kenneth J. Mishark, FACP.

“Not a lot of hospital training is provided in PA training because it is primary-care-based,”
explained Kristen K. Will, PA-C, also from the Mayo department of hospital medicine.
“All PAs coming out of PA school are really trained for primary care. If they
work in a specialty, then all of the training is really on-the-job training.”

The Mayo hospitalist program had provided that sort of training to PAs but the process
was time-consuming and not entirely efficient. “We still found it took them
at least six months to a year with prior experience to get up to the efficiency level
[expected of hospitalist PAs],” Ms. Will said.

Ms. Will and Dr. Mishark eventually came to the conclusion that PAs needed a more
formal training program. With approval from the hospital, Ms. Will, who has a master's
degree in health professions education and experience teaching PAs, developed a curriculum
for the country's first year-long postgraduate training program for hospitalist PAs.

How it works

The training program, officially called the Mayo Clinic Arizona Physician Assistant
Fellowship in Hospital Medicine, enrolled its first trainee in October 2007.

The curriculum was based on core competencies from the Society of Hospital Medicine,
standards from the Accreditation Review Commission in Education for the Physician
Assistant (ARC-PA), and the experience and knowledge of Ms. Will, who now serves as
the clinical director of the program. “I'm a hospitalist PA. I kind of know
what it takes to learn how to do what I do,” she said.

During the year-long program, the PA fellows complete self-directed teaching modules,
receive didactic instruction and go through 12 to 14 rotations (including night and
day hospitalist service and specialties such as cardiology and endocrinology). Parts
of the training overlap with that of the hospital's medical residents; there are shared
rotations and joint attendance at educational lectures and grand rounds.

Since the program is accredited by the ARC-PA, the fellows are subject to the usual
duty-hour restrictions. They receive an educational stipend of $44,000 and benefits.
“Pretty much all the normal benefits that would be offered to the staff PAs
are offered to the fellows,” said Ms. Will. At the end of the year, the trained
PA receives a certificate of completion.

Challenges

The developers of the program had to overcome some concerns from hospital leaders
in order to get the project approved.

“One of the main things that we had to convey was that we were not at all going
to take away from the learning experience of the medicine residents,” said
Ms. Will. The PA fellowship does share some specialty rotations with the residents,
but there's no competition for cases or procedures, she said.

The other major hurdle was funding the program budget of $99,500 per year. “Our
training dollars are getting limited. We had to convince the institution that this
added value in training, and we were able to do that,” said Dr. Mishark.

Results

So far, two PAs have graduated from the fellowship, and anecdotally at least, they
learned a lot more than they would have in typical informal training. “The
velocity of learning is just greater. We see the graduates one year out are functioning
as though they have three to four years of experience,” said Ms. Will.

Although it's not a requirement or even an expectation of the program, both graduates
took jobs with the Mayo hospitalist program. “If there are positions open near
the end of the PA fellow's time with us, we encourage them to apply and they're almost
without a doubt the first and only candidate,” said Ms. Will.

One of the graduates did look at other employment options and found that the fellowship
expanded her opportunities. “She was offered positions at numerous well-respected
institutions. Having the fellowship on her CV really helped,” Ms. Will said.

The graduates also contribute more in the non-clinical sphere than typical new hires,
Ms. Will said. “They've become leaders in our department, already involved
in committee work and education training programs.”

Lessons learned

Ms. Will spent about 300 hours developing the PA fellowship curriculum and she recommends
that other hospitalist programs also devote significant planning. “Have a clearly
outlined curriculum that really fits the needs of the institution and the needs of
the midlevel provider,” she advised.

Hospitalists looking to follow in the Mayo program's footsteps can save some of that
time and effort by picking up components of the existing curriculum, which Ms. Will
and Dr. Mishark are eager to share. Details are available in the February Journal of Hospital Medicine or on the program's website.

How others benefit

The program has had unexpected benefits for the physicians involved in teaching the
PAs, according to Dr. Mishark. “As an educator, it's pretty darn rewarding
because you see them go from not really understanding how to put in orders to being
very, very confident in their year of training. Compared to an ordinary medicine resident,
the pace of learning is much faster. It really reflects that they haven't had a lot
of hospital experience.”

The resident physicians also gain from the shared training. “The future of
medicine really is going to involve collaboration between midlevels and providers
and that synergy has been very, very helpful because they go through rotations together.
They learn from each other,” Dr. Mishark said.

The program leaders hope that other hospitals will see the benefits and get on board.
“There's a shortage of hospitalist physicians and there's a shortage of hospital
staff,” noted Ms. Will. “We don't think that our program can fill the
needs of the national hospitalist shortage, but it's certainly an attempt to start
a movement.”

Next steps

Currently, the program accepts only one PA fellow per year, but the leaders hope to
expand it to a second PA and possibly nurse practitioners soon. “We wanted
to make sure that we did it right, so we did it with one person. Now that we know
it works and it's well accepted, hopefully we can expand it in years to come,”
said Ms. Will.

They also plan to gather data on the results of the fellowship program, to provide
quantifiable support for the benefits of the training.

Words of wisdom

“The reason this program works is based on the mutual respect between the providers
and the PAs, and that's critical,” said Dr. Mishark. “This isn't a master/slave
relationship.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.